Stephen Marmaras: Step Therapy

Transcript:

What is your organization’s position on step therapy?

So, step therapy is a topic that causes a lot of emotion from our community members—from people living with chronic disease. Most of our membership have experienced step-therapy at one point or another. We understand in concept why insurers use step therapy, [but] we think it’s like using a hatchet to attempt a surgery. It really is kind of a 1-size-fits-all practice that really isn’t applicable.

We think medicine is so nuanced, and especially the patients in our community live with very complex chronic diseases, [so] you cannot make a policy as encompassing as a step therapy, or like folks in our community like to call it, “fail first,” that is going to work for everyone.

We understand generally why it’s in place. We think it’s appropriate in some cases, but for the vast majority of the instances we think it’s very inappropriate, and we would argue even unethical.

I think that we’re encouraged to see many states across the country starting to implement legislation that has been introduced—a newer version of step-therapy legislation—that was introduced starting around 2015 that is much stronger than previous attempts that don’t look to just prohibit step-therapy, because we understand that that’s not reasonable. But it looks to put some guard rails in place or it looks to really protect the patient from the step therapy practices going too far.

If we look at New York, for instance, legislation was passed in our home state through the efforts of a very diverse coalition of many, many patient groups—I believe there were over 60 patient groups that worked together to get that bill passed. But that bill, what it specifically did and now does under law, it mandates that step therapy protocols are developed using clinical criteria and that that clinical criteria are really [coming from] a third party [such as] a professional society, [or] a professional college of medicine. It’s under the direction of medical information, not financial information.

Number 2, it sets out clear criteria for which a physician and their patient can use to appeal a step-therapy policy. One of the more critical parts of the legislation is that it puts in place a time requirement for which the insurer has to respond to that appeal.

So, in New York, that’s 72 hours, or in the case of an emergency [it’s] 24 hours. That’s a really important part, because when we go to state capitols across the country with other groups to advocate for this type of legislation, many times we hear from folks on the other side “well, we already have an appeals process in place.” But when you’ve seen 1 insurer’s appeals process, you’ve seen 1 insurer’s appeals process. There’s no uniformity. This drives physicians crazy, it drives patients crazy because people are changing their insurance plans from time to time and 1 of the largest complaints we hear is that I file an appeal, but just because I file an appeal doesn’t mean anything. We’ve heard patients wait up to 130 days before they get a response to an appeal.

It’s really critical that that protection be a part of the legislation, and so we’re working to pass that in many other states. I would direct folks to 1 of our websites, failfirsthurts.org, where we track a lot of this legislation and we list out many of these kinds of principles that I just spoke about.